Rise of the doula: a helping hand or a danger to mothers?

Rise of the doula: a helping hand or a danger to mothers?
thetimes.com/article/b16bda96-c82b-4dd0-8214-812f82675895

With trust in NHS maternity services at a low, women are turning
to private midwives and doulas, some with extreme views on
childbirth. But what happens when that dream home birth goes
wrong?

Rosie Kinchen
Saturday June 22 2024, 9.00pm, The Sunday Times

It’s 11pm on a Tuesday night and I’m on a home-birth forum. A mother has posted a
triumphant story. She has delivered a daughter at home. It is a BBA (born before arrival),
the term applied when a baby arrives before the midwives do — only in this case that was
intentional. At the top of the post is a list of the risk factors the mother has overcome or
ignored in delivering her child like this, including a haemorrhage during a previous birth
and a high body mass index (BMI). The congratulations pour in. She has birthed the way
she wanted to; she has defeated the system and won. But what of those who don’t?

When I found out I was pregnant again last autumn, seven years after I gave birth to my
first child and five years after my second, I was expecting things to have changed. The
maternity world is as subject to fashions and fads as any other — more so, perhaps.

There would be a new must-have buggy, a new guru expounding the latest theory on how
to get a grizzly infant to sleep. What I wasn’t expecting was for the landscape of birth to
have transformed as radically as it has.

For the past three months I’ve been observing these changes, trying to understand the
causes and the risks they raise. What I found is that, against a backdrop of struggling
NHS maternity services and a nervousness about the quality of care they provide, the
private maternity sector is booming. Faced with a shortage of midwives in hospitals and
poor continuity of care, pregnant women are increasingly hiring doulas — trained
childbirth companions who often work alongside NHS midwives to provide non-medical
support before, during and after birth. Others are seeking out independent midwives, who
are qualified professionals working outside the NHS. And growing numbers are turning to
radical “birthkeepers”, some of whom advocate rejecting medical intervention altogether.

Underpinning much of this is a feminist message: that a woman should give birth the way
she wants to. But while there is nothing wrong with wanting extra support in the most
critical of life events, as some upsetting cases have shown, turning away from the NHS
does not guarantee a smooth labour, nor the health of a baby and its mother. In the very
worst scenarios it can result in catastrophe.

Broken trust

My first child was born in 2017, the same year that the investigation into maternity failures
at Shrewsbury and Telford Hospital NHS Trust began. The final report on the scandal, led
by the senior midwife and healthcare leader Donna Ockenden, described in detail how
between 2000 and 2019,201 babies and nine mothers could or would have survived had
the trust provided better care. Ockenden is now leading another inquiry into similar
failings in Nottingham.

Since then, Ockenden says, “progress has been extremely patchy”. The government has
failed to meet investment targets set by the health select committee and endorsed by the
Ockenden report for £200-£350 million a year urgently to be put into maternity services.
The result is an increasingly desperate situation. “I speak to staff daily and there is a
palpable level of distress in caregivers that they do not have time to care,” Ockenden
says.

Donna Ockenden, the senior midwife and healthcare leader

JACOB KING/PA

Half of Britain’s maternity units have been rated as failing and maternity negligence
makes up the bulk of NHS medical payouts. Last year the NHS in England spent £1.1
billion settling such claims — a third of the NHS’s budget for these services. The first
parliamentary inquiry into birth trauma, published last month, stated that good care for
pregnant women and new mothers is “the exception rather than the rule”. New mothers
are dying in greater numbers than at any point in the past 20 years. About 20,000 women
a year suffer from postnatal post-traumatic stress disorder due to their experiences in the
labour ward.

It is this climate of fear that has encouraged parents-to-be to seek private care —
sometimes from people with few qualifications or little medical expertise. In this new world
where deep cynicism about the NHS mixes with spurious medical advice and ideology,
pregnant women are left wondering who they can trust.

A helping hand

The crisis in maternity care is being driven partly by a shortage of about 2,500 midwives.
Twenty years ago, a woman would have had one midwife who stayed with them
throughout pregnancy. Today they are unlikely to have the same midwife through labour.

Step forward the doulas. Taking their name from the ancient Greek for female slave, the
idea took off in the 1970s alongside the natural birth movement, but in recent years they
have become a newly valuable source of support for those who can afford them. What
exactly they offer varies but they can help supply the sort of one-to-one continual care
that NHS midwives can’t always provide. While they are not medically trained and cannot
carry out the clinical duties of a midwife, they can help prepare for birth, working through
fears and nerves, and provide massage, breathing techniques and support during labour.
In the gruelling postpartum weeks, many will make healthy meals to go in the freezer,
give advice on breastfeeding and help with childcare and light housework. No wonder that
in middle-class birthing circles, a good doula is as sought-after as a nanny.

There are 700 doulas registered with Doula UK, the body that represents this sector. Its
members assisted in more than 2,000 births in 2022, up from 1,835 the previous year,
and numbers are expected to rise again this year. Plenty more operate independently.

The investigation into maternity failures at Shrewsbury and Telford Hospital NHS Trust began in 2017.

JACOB KING/PA

Many women rave about their doulas, crediting them for a positive birth experience.
Phoebe Jones, 38, hired a doula for the birth of her son two years ago. During her
pregnancy she had needed a cervical stitch and spent a lot of time in hospital. It was the
tail end of lockdown, she says, and staff were exhausted. “No one had any time. The
human aspect had gone.”

She began to have panic attacks whenever she had a hospital appointment, which led
her to opt for a home birth, supported by her local south London NHS trust’s home-birth
team. “My husband was telling me I was doing a good job when I was in labour,” she
says, “but I couldn’t really believe him because he’d never been in this position before.”
When her doula told her all was going well, Jones believed her. “She was also making
sure that I was eating and going to the toilet.”

She paid £2,000 for the whole package, which included antenatal support from 30 weeks,
being on call for the birth and a three-hour aftercare session where they discussed diet
and nutrition. It was such a positive experience that Jones hired the same doula again for
the birth of her daughter last month.

Many doulas see themselves as an intermediary between their clients and a health
service that, they argue, may not have their interests at heart. Rebecca Robertson, 38,
gave up a career as a fundraiser to be a full-time doula after having a traumatic first birth
in an NHS hospital and an empowering second one at home. She charges £1,200 for a
birth package and says one of the main strands of her job is helping women to “navigate
the NHS system”. “Most women go into pregnancy and birth assuming that the system
they pass through is set up with their best interests in mind,” Robertson says. Her clients
have often realised this is not the case. According to Robertson, “the policies in hospitals
are not necessarily woman-centred. Policies and guidelines often lack an evidence base;
they are done for convenience or fear of litigation.”

Rebecca Robertson is a full-time doula. She says her business is booming: ‘I turn down births’

MIKE SIM

She says she supports women with whichever birth they choose. Midwives are usually
grateful to have her in the room. “I’m in awe of midwives. They do an incredible job,” she
says. “They are underfunded and overworked, and in some ways I’m great because I’m
an extra pair of hands.” The relationship with obstetricians can be more complicated. “If
you have an obstetric emergency, then you want an obstetrician. But in my experience
they are deployed more often than they are required,” she says.

Robertson has been booked by several clients who had traumatic first births during
lockdown, when Covid-19 caused mayhem in NHS maternity care with partners banned
from wards, and want her reassurance the second time around. The doula community is
close-knit, she says. “There are more inquiries than we can collectively cover. I turn down
births,” she says.

Not everyone has a good experience. One woman I spoke to said that her doula had
arrived late and then let her walk to the maternity unit in active labour while she parked
the car. During the birth there were no reminders of breathing techniques or words of
encouragement. “She sat there on her phone and ate my snacks,” she said. She had
spent £800 on someone who was “as useful as a chocolate teapot”.

Doulas are not government regulated. But to register with Doula UK a doula must have
done an approved course, which can last from four days to several weeks, and spent time
working with a mentor. Their code of conduct specifies, among other things, that doulas
provide “practical and emotional support, but not advice” or medical guidance. There is a
dispute resolution service for unhappy clients. The volunteer director Trudi Dawson says
they deal with three or four cases a year.

Suzie, who is British, hired a doula because she had just moved to Los Angeles and felt
uncomfortable in a new system. They got along well until they came to the delivery suite.
After several hours of labour the obstetrician said the baby was becoming distressed.
“They tried a few things but ultimately they said, ‘I think you need to have a c-section.’ ” At
this point Suzie’s doula tried to delay the surgery. “She created a very weird environment.
My husband said it was like having a sulky teenager in the room.” The operation
eventually went ahead but Suzie feels she should have agreed much sooner.

The free-birth radicals

The loss of trust in the NHS is driving some women to extreme options. Ockenden says
she has spoken to colleagues, including midwives and obstetricians, “and there is
definitely an increase in the number of women choosing unassisted birth”. This practice,
known as freebirthing, is being encouraged by certain self-described “radical
birthkeepers”. Samantha Gadsden runs a home-birth group on Facebook with 15,000
members and a freebirth forum, which women and birthkeepers pay to join (£50 and £65
respectively). She launched it during the pandemic in response to growing demand when
many trusts stopped offering home-birth services.

Today, home-birth provision in the NHS continues to be patchy. According to the birth
charity Aims, trusts will offer some kind of home-birth service but some will do so only
between set hours or on fixed days of the week. Online alternative-birth forums are
thriving. Gadsden, who charges £1,995 for a doula service, advises that the best way to
avoid perineal tearing is by “listening to your own body”. She has posted an account by
Jenny Wren, a “hearthkeeper”, about why she has declined ultrasound during pregnancy.

She links to an article suggesting that chewing on your placenta can stop a postpartum
haemorrhage. “That is clearly rubbish,” says Pat O’Brien, a consultant obstetrician at
University College London Hospitals trust. “There is no reliable evidence to support that.”

Gadsden says: “Families, mothers and babies are being failed by NHS maternity services
I have built trust with my community, supporting them to do their own research and make
their own informed decisions.” She adds that her “priority is always the safety and
emotional and physical wellbeing of families, mothers and their babies”.

Kemi “Birthjoy” Johnson, a former midwife turned activist, is one of the most militant
voices. She charges £160 for a Zoom consultation and £220 for a birth reflection session.
In one video posted to her 33,000 followers on Instagram last year, Johnson tells women,
“Too many of you are sleepwalking into maternity services and getting f***ed by a
malevolent maternity mafia who do not care about your health or the health of your child.”
She has said that freebirthing is “for parents who want the healthiest birth for them and
their children”.

Kemi ‘Birthjoy’ Johnson, a former midwife, is one of the most outspoken freebirth activists

KEMI “BIRTHJOY” JOHNSON / INSTAGRAM

Ockenden is concerned about the number of women who are choosing this path.
“Freebirthing sounds romantic but it’s not. It’s bringing new life into the world without
skilled midwifery or medical assistance and I do know a number of cases across England
with extremely tragic outcomes for mothers and babies.”

Worst of all worlds

Elisha Harris and her husband, Ashley, both 29, found themselves caught between an
overstretched health service and an alternative world of self-appointed “experts”. She was
left traumatised by the birth of her first child, Theo, when she was 17. She’d been
induced, had a forceps delivery and suffered from postnatal depression. In 2020, after her
trust had cancelled home-birth services during the pandemic, her daughter, Maeva, was
born at home supported by an independent midwife. “It was like therapy. I realised that
actually I didn’t do anything wrong the last time,” she says.

There is growing demand for private midwives, who are qualified and registered with the
Nursing and Midwifery Council. Like doulas, they offer continuity of care, which research
repeatedly shows pregnant women prefer. But questions have been asked about the
standard of their training. One to One, a private midwifery agency that had an NHS
contract to work in the Wirral and boasted a high home-birth rate, was the subject of a
review in 2014 after two babies died. It later declared bankruptcy.

Today, the majority work through two agencies: Independent Midwives, which employs
midwives as staff and is regulated by the Care Quality Commission; and Zest, which
gives midwives “autonomy” to pursue “physiological birth choices” and is not registered
with the CQC or regulated by it. They match midwives with insurers willing to cover them.
Each agency has about a hundred midwives on their books and say they are struggling to
meet demand.

When she became pregnant again in 2022 Elisha hoped to have another home birth,
supported by the NHS. But she was expecting twins and her local trust, she says, was
reluctant to help. She says that no one on the home-birth team had the relevant skills.
The NHS advises against home births for twins because of the greater risk of
complications, but it is ultimately a woman’s choice and her local trust has a duty to
support her. When the head of midwifery came to see them, Ashley, says, “It turned into
them saying we’d need three ambulances outside your house on standby,” and warning
that “there would be questions about our mental health as parents”.

Elisha had already hired a doula, Abi, and both were members of Gadsden’s home-birth
groups. Abi paid for access to Gadsden’s guide on twin births and helped to find an
independent midwife, Katie, through Zest. The cost to the couple would be £10,000. They
wanted to be registered with a hospital as well in case something went wrong. They went
to the Rosie Hospital in Cambridge for Elisha’s 36-week scan and the sonographer raised
concerns about the development of one of the twins.

The couple were referred to an obstetrician who advised them the babies should be
delivered immediately. “She said, ‘We’re concerned about the growth. I don’t think twin
two will survive labour,’ ” Ashley recalls. The couple were shocked and wanted to weigh
up the risks of a premature delivery. According to them, the more questions they asked,
the more flustered the consultant became. After about ten minutes, they say, the
consultant left them in the care of the lead midwife. At this point Elisha says they did not
know what to think. They called Katie who, they say, told them that growth scans were
unreliable.

The couple left and decided to return to the hospital the following week. Their next
appointment with Katie was two days later. “She listened to the babies’ heartbeats and
said, ‘I can hear exactly what I should be hearing,’ ” Elisha says, and did not find any
problems with the cardiotocography (CTG) results, which record foetal heart rate.

Elisha Harris with her son Lawson, whose twin, Layton, was stillborn.
Elisha feels let down by both the NHS and the independent midwife she had hired to help.

JASON BYE

Reassured, Elisha decided not to return to the hospital as planned. Instead she immersed
herself in the natural-birth world. She saw Kemi Johnson posting about a woman
pregnant with twins who had been advised by her NHS trust to have a caesarean and
had refused. This “queen”, Johnson wrote, had delivered her babies at home. Elisha
replied saying that she was in the same boat. “Once you’ve had your babies can you
contact me? I’d love to share your story,” Johnson responded.

Over the next three weeks Elisha had several more phone calls from Cambridge
University Hospitals NHS Foundation Trust and continued to turn down further CTG
monitoring.

On April 29, at nearly 40 weeks pregnant, she had another appointment with Katie, who
struggled to find a second heartbeat. According to Elisha, Katie suggested she could go
fora scan, but Elisha’s impression was that Katie didn’t think it was essential. On May 3,
her contractions started. Her first twin, Lawson, was born at home on the morning of May
4, with Katie and the couple’s doula, Abi, by her side. After a short pause, her second
son, Layton, followed. She knew there was a problem straight away. “He didn’t cry,”
Elisha says. “As soon as I touched him, he felt soft. I thought, ‘This doesn’t feel right.’ ” An
ambulance took them to the hospital where they were told a postmortem examination
would be carried out. “It was such a shock,” Elisha says.

They now believe that he was experiencing placental insufficiency: when the placenta
begins to run down, which can lead to reduced growth. The couple say the term was
never mentioned by medical staff, nor was the condition explained.

There was an internal review into their case last year, during which a consultant agreed
that placental insufficiency was the most likely cause of death. However, the review
concluded that the parents were warned of the risks. The trust rated its level of care as
grade A.

A spokesperson at Cambridge University Hospitals NHS Foundation Trust said: “Our
deepest condolences are with Ashley and Elisha Harris and their family for the loss of
baby Layton. We have thoroughly reviewed Elisha’s maternity care and found all
protocols and procedures were fully complied with and in line with clinical guidance. Our

top priority is always patient safety and care.” Elisha and Ashley were not included in the
process and are considering legal action. They feel that if the condition had been
discussed and properly explained they would have followed the guidance.

It is not just the NHS by which they feel let down, but the private carers they put their faith
in. Elisha believes there is a whole sector of well-intentioned people offering support they
are not qualified to give: “They say, ‘I’m non-clinical,’ or, ‘This is just advice,’ and they use
it like a get-out-of-jail-free card — they can’t be held accountable for what they have
said.”

Knowing the risks

In 2022 the Royal College of Midwives published guidelines advising its members how to
provide care for women who choose not to follow medical advice. Sara Ledger, head of
research and development at the charity Baby Lifeline, which provides training to qualified
midwives, has said: “We hear from a lot of midwives that many women now want to give
birth outside of guidance. I think a lot of public trust has gone, because of media scrutiny
of maternity services and, quite rightly, a lot of family voices coming out, seeking justice
because their babies have died.”

According to Kim Thomas, CEO of the Birth Trauma Association, home births can be very
successful in low-risk pregnancies, but avoiding hospital does not guarantee a good
delivery. About 45 per cent of home births for first babies end up with a hospital transfer,
dropping to about 12 per cent with subsequent children. Moreover, Thomas says, many
cases that were heard during the birth trauma inquiry involving instrumental deliveries —
forceps resulting in tearing, for example — “seemed to happen because the intervention
happened too late”.

The home-birth community, which was once so supportive to Elisha, is proving less
interested now that things have gone horrifically wrong. She has been blocked from the
home-birth group. Meanwhile Zest, the midwife agency she used, has posted promotional
material on social media claiming to have delivered twins without mentioning that one of
the babies died. A spokesperson for Zest said: “We are aware that the consultant advised
the parents and they made a choice to give birth at home. Zest-registered midwives
respect the need for multidisciplinary teamworking and always respect client choice on
their birth journey.” Ashley is appalled. “You are using my children for advertising, yet you
don’t acknowledge that one of them is not here,” he says.